Characterization of elderly people with an intestinal stoma at a reference center in the state of Bahia

1.Escola Bahiana de Medicina e Saúde Pública – Curso de Especialização Enfermagem em Estomaterapia – Salvador/BA – Brasil. 2.Universidade Federal de Minas Gerias – Escola de Enfermagem – Departamento de Enfermagem Básica – Belo Horizonte/MG – Brasil. 3.Universidade Federal de Minas Gerais – Escola de Enfermagem – Belo Horizonte/MG – Brasil. *Correspondence author: eborges@ufmg.br Received: Jan. 10, 2019 | Accepted: Nov. 11, 2019 ABSTRACT Objective: To characterize the elderly patients with intestinal stoma, enrolled in a Reference Center of the public health network of the state, regarding sociodemographic and clinical aspects. Method: This is a cross-sectional descriptive study with a sample of 33 elderly patients with intestinal stoma who met the inclusion criteria. Data were extracted from the medical record, interview and evaluation of the stoma and surrounding skin, analyzed through descriptive statistics. Results: patients underwent surgery in public and private hospitals, 54.5% were female, 51.6% married or in stable union, mean age was 68.03 (± 7.2) years, 69.7% had cancer as a cause of the stoma, 66.7% were temporary and 81.8% were colostomies. There was a predominance of stomas with a regular and round shape, diameter between 10 and 64 mm and a mean protrusion of 2.79 mm (± 5.1), use of a drainage bag with a cut greater than the stoma, 51.5% for stoma and device care. Conclusion: the study allowed to identify the profile of the elderly with intestinal stoma, which will allow the adjustment of the specialized assistance planning and the provision of collecting equipment and adjuvants in the context of the state.


INTRODUCTION
In developed countries with high income per capita, life expectancy has increased in recent decades. The decrease of some risk factors contributed to this event.
The main factors are reduced tobacco consumption and mortality from cardiovascular diseases (both for men and women) 1 .
Aging is part of the reality of the society in developed or developing countries, represented by the reduction of the number of children and young people and the increase of people aged 65 and over. This statement is supported by the estimate that by 2050 there will be two billion elderly people worldwide 2 .
Increased life expectancy, an aging population, and effective screening programs for colorectal cancer have led to an increase in the number of people with an intestinal stoma (ileostomy and colostomy) in several countries 3 . Even the number of elderly people with a stoma is expected to increase in the coming years as well 4 .
Genetic, environmental, and lifestyle-related aspects can influence the appearance of colorectal cancer, considering that this is a multifactorial disease. The geographical differences observed in the incidence of the disease possibly reflect the adoption of western habits, especially those related to sedentarism and a diet deficient in fiber and rich in red meat 5 .
Several studies conducted in Brazil to characterize patients with elimination stoma identified a predominance of elderly people [6][7][8][9] . Despite this tendency, there are few epidemiological studies conducted exclusively with elderly patients. Therefore, it is inferred that there are differences in care demands between adult and elderly patients with a stoma.
The authors of a study on elderly people with intestinal stoma identified that these people did not accept their health conditions, culminating in treatment rejection. This attitude resulted in occupational and social damage for these patients, with loss of self-esteem and social and family isolation 10 .
Therefore, the present study aims to elucidate the question regarding the sociodemographic and clinical profile of elderly patients with stoma treated in the reference center of the state of Bahia, Brazil, considering the absence of these records in the official state documents.
It is expected that this study on elderly people with stoma might support the managers and nurses, especially the specialists in enterostomal therapy, in planning health actions, forecasting, provision of inputs, the assistance provided, and, finally, the organization of services for the care of elderly users.

OBJECTIVE
The study aimed to characterize, in terms of sociodemographic and clinical aspects, elderly patients with intestinal stoma registered in a reference center of the public health network. From July to October 2018, when data collection for the study was conducted, 1,807 users were registered, and 1,445 attended. Of these, 1,012 (70%) were attended by the legal representative and 433 (30%) in person (Fig. 1).

METHODS
The sample was convenient, i.e., not probabilistic, due to time and resource limitations. To participate in the study, the user complied with the following inclusion criteria: to be registered in the reference service with presential attendance, to be 60 years of age or older, to have some type of intestinal elimination stoma (ileostomy or colostomy) and to be able to answer the interview questions and undergo physical evaluation with the removal of the collector device for evaluation of the stoma and the surrounding skin.
All participants used drainable collector device, 32 of them (97.0%) with cuttable base, whose cutout ranged from 15 to 70 mm, and 12 (36.3%) participants needed adjuvants, with 7 using one product (synthetic resin paste), 2 using two products (synthetic resin paste with paste or with belt), and 3 using three products (synthetic paste and powder, and belt). All participants stated that they had received a sufficient number of collectors and adjuvant devices for the established period.
The number of device changes per week varied from one to seven times (Table 2).
Regarding the cutout of the collector device plate, 23 (69.7%) participants had an orifice larger than the stoma, ranging from 4 to 39 mm (Fig. 2).
Regarding the effluent consistency, 15

DISCUSSION
The achieved results are essential for future interventions in the planning and improvement of   The treatment of this disease, in most cases, involves the performance of surgery that leads to the confection of an elimination stoma, i.e., ileostomy or colostomy.
Lifestyle-related risk factors include consumption of alcoholic beverages, low fruit and vegetable intake, high consumption of red meat and processed foods, obesity, smoking, and physical inactivity 19 .
Age is a factor that seems to contribute to colorectal cancer mortality. This data was confirmed by a study conducted in the state of Rio de Janeiro, which identified the correlation of age with the increased mortality rate The adaptation time after the surgery is peculiar to each person with stoma 26 . It is noteworthy that in a study of 526 people of various ages with an intestinal stoma, the authors found that the elderly patients had no more limitations or psychosocial impact due to the stoma compared to their younger peers. Over the years, the impact becomes less distinct 27 .
In this study, it was evident that the reason for not performing self-care was mainly related to denial of health status. Similar data were obtained from a study conducted in the Netherlands, whose aged ≥ 80 years of age needed help or assistance to empty or replace the bag, mainly due to the inability to reach or accurately visualize the stoma 27 .
In In this study, the limiting factors found in the collection phase were the absence of the user himself, due to the constant representation by legal representatives and/or family members in the service to receive the collector devices, the existence of only one room for consultation with the nurse, the refusal of the patient to participate in the research because he had to remove the collector device for assessment of the stoma and surrounding skin, even knowing that another device would be placed during the nursing consultation. The above reasons reinforce the need for comprehensive studies in Brazil.
The results of this study obtained from a small sample of users revealed several weaknesses that could help the health team in the actions aimed at this public formed by elderly people and allowed to establish some implications for rehabilitation: • Helping elderly people with a stoma to develop competent stoma self-care skills will promote selfacceptance and self-care; • Nurses should promote access to referral services for elderly people with a stoma to adapt to new living with a stoma; • Gradual exposure to social participation can generate feelings of control and confidence for people with a stoma.
The need to reorganize the care service network, to establish strategies to improve the care provided to elderly users, in addition to ensuring the acquisition and standardization of collecting equipment and protection and safety adjuvants that meet the individual needs of these users is highlighted. Decision making in the treatment of the elderly person with an intestinal stoma is challenging, which demands strategies aimed at rehabilitation since the preoperative period.

CONCLUSION
The study identified the profile of elderly users with an intestinal stoma of the reference center of the state of Bahia. The patients presented limitations for selfcare, used a drainable device regardless of the type of stoma, the pattern of elimination, and the characteristic of the effluent. The cutout of the device plate was more significant than the diameter of the stoma, increasing the risk of dermatitis. Many were represented by a family member or a legal representative.
The findings of the study will enable the adequacy of the planning of specialized assistance, the provision of collection equipment, and adjuvants in the context of the state of Bahia.